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This is VAERS ID 917882

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History of Changes from the VAERS Wayback Machine

First Appeared on 1/7/2021

VAERS ID: 917882
VAERS Form:2
Age:49.0
Sex:Female
Location:New Jersey
Vaccinated:2020-12-22
Onset:2020-12-22
Submitted:0000-00-00
Entered:2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Anaphylactic reaction, Dizziness, Dyspnoea, Erythema, Flushing, Nausea, Palpitations, Respiratory distress, Swollen tongue, Wheezing, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Biotin 1 mg PO daily, Levothyroxine 112 mcg PO daily, MVI tablet PO daily, Paroxetine 20 mg PO QHS
Current Illness: none reported
Preexisting Conditions: Past Medical History (as noted in H&P) ? Acquired hypothyroidism ? ? Anxiety ? ? Chronic deep vein thrombosis (DVT) of distal vein of lower extremity ? ? Chronic midline low back pain ? ? Complex regional pain syndrome I ? ? Essential hypertension ? ? Fibromyalgia ? ? Gastroesophageal reflux disease without esophagitis ? ? History of pseudoseizure ? ? Laryngospasm ? ? MDD (major depressive disorder) ? ? RSD (reflex sympathetic dystrophy)
Allergies: cefuroxime (shortness of breath), gadolinium (anaphylaxis, March 2018), iodine (anaphylaxis), quinolones (shortness of breath, "paralyze"), gabapentin (hallucinations), vancomycin (itching)
Diagnostic Lab Data: COVID-19 antigen negative, BP 126/52, pulse 96 on admission to ED
CDC 'Split Type':

Write-up: Patient is hospital employee who completed screening form for COVID-19 vaccine by answering "no" to all contraindication questions. Approx 10 minutes after receiving COVID-19 vaccine dose # 1, patient was still in vaccine clinic area and complained of dizziness, palpitations and flushing. I observed patient fanning herself with papers. She was escorted out of the immediate clinic room, and assessed by paramedics present as having an anaphylactic reaction. Epinephrine 0.3 mg IM and diphenhydramine 50 mg IV given in clinic, Rapid Response was called overhead and patient immediately transported down the hall to the Emergency Dept. In ED, pt was noted as having swollen tongue, large areas of erythema on face, arms and chest, shortness of breath, nausea, dizziness (per ED physician notes). Pt reported being hospitalized in ICU with COVID disease more than 3 months ago, including intubation (not treated at this hospital), and has been back at work since August 2020. ED physical exam noted bilateral wheezing and patient in acute distress. In ED, pt administered racemic epinephrine 2.25% 0.5 mL via neb, epinephrine 0.3 mg IM, diphenhydramine 50 mg IV, Solu-Medrol 125 mg IV, famotidine 20 mg IV and epinephrine 5 mg/250 mL IV drip (started at 0.118 mcg/kg/min). Acute symptoms reported to resolve in ED. COVID test was negative. ED physician discovered that pt had history of multiple medications, including previous anaphylactic reaction to radiocontrast dye requiring intubation (which was not disclosed on the vaccine screening form). Pt admitted to Telemetry floor for observation. Overnight course was unremarkable, and patient was discharged the following day with prescription for Prednisone taper and prescription for Epi-pen. Advised not to return for second dose of COVID vaccine. EMR updated to reflect possible anaphylactic reaction to Moderna COVID-19 vaccine.


Changed on 5/7/2021

VAERS ID: 917882 Before After
VAERS Form:2
Age:49.0
Sex:Female
Location:New Jersey
Vaccinated:2020-12-22
Onset:2020-12-22
Submitted:0000-00-00
Entered:2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Anaphylactic reaction, Dizziness, Dyspnoea, Erythema, Flushing, Nausea, Palpitations, Respiratory distress, Swollen tongue, Wheezing, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Biotin 1 mg PO daily, Levothyroxine 112 mcg PO daily, MVI tablet PO daily, Paroxetine 20 mg PO QHS
Current Illness: none reported
Preexisting Conditions: Past Medical History (as noted in H&P) ? Acquired hypothyroidism ?   ? Anxiety ?   ? Chronic deep vein thrombosis (DVT) of distal vein of lower extremity ?   ? Chronic midline low back pain ?   ? Complex regional pain syndrome I ?   ? Essential hypertension ?   ? Fibromyalgia ?   ? Gastroesophageal reflux disease without esophagitis ?   ? History of pseudoseizure ?   ? Laryngospasm ?   ? MDD (major depressive disorder) ?   ? RSD (reflex sympathetic dystrophy)
Allergies: cefuroxime (shortness of breath), gadolinium (anaphylaxis, March 2018), iodine (anaphylaxis), quinolones (shortness of breath, "paralyze"), gabapentin (hallucinations), vancomycin (itching) (itching)
Diagnostic Lab Data: COVID-19 antigen negative, BP 126/52, pulse 96 on admission to ED
CDC 'Split Type':

Write-up: Patient is hospital employee who completed screening form for COVID-19 vaccine by answering "no" to all contraindication questions. Approx 10 minutes after receiving COVID-19 vaccine dose # 1, patient was still in vaccine clinic area and complained of dizziness, palpitations and flushing. I observed patient fanning herself with papers. She was escorted out of the immediate clinic room, and assessed by paramedics present as having an anaphylactic reaction. Epinephrine 0.3 mg IM and diphenhydramine 50 mg IV given in clinic, Rapid Response was called overhead and patient immediately transported down the hall to the Emergency Dept. In ED, pt was noted as having swollen tongue, large areas of erythema on face, arms and chest, shortness of breath, nausea, dizziness (per ED physician notes). Pt reported being hospitalized in ICU with COVID disease more than 3 months ago, including intubation (not treated at this hospital), and has been back at work since August 2020. ED physical exam noted bilateral wheezing and patient in acute distress. In ED, pt administered racemic epinephrine 2.25% 0.5 mL via neb, epinephrine 0.3 mg IM, diphenhydramine 50 mg IV, Solu-Medrol 125 mg IV, famotidine 20 mg IV and epinephrine 5 mg/250 mL IV drip (started at 0.118 mcg/kg/min). Acute symptoms reported to resolve in ED. COVID test was negative. ED physician discovered that pt had history of multiple medications, including previous anaphylactic reaction to radiocontrast dye requiring intubation (which was not disclosed on the vaccine screening form). Pt admitted to Telemetry floor for observation. Overnight course was unremarkable, and patient was discharged the following day with prescription for Prednisone taper and prescription for Epi-pen. Advised not to return for second dose of COVID vaccine. EMR updated to reflect possible anaphylactic reaction to Moderna COVID-19 vaccine.


Changed on 5/14/2021

VAERS ID: 917882 Before After
VAERS Form:2
Age:49.0
Sex:Female
Location:New Jersey
Vaccinated:2020-12-22
Onset:2020-12-22
Submitted:0000-00-00
Entered:2021-01-03
Vaccin­ation / Manu­facturer Lot / Dose Site / Route
COVID19: COVID19 (COVID19 (MODERNA)) / MODERNA 011J20A / 1 LA / IM

Administered by: Private      Purchased by: ??
Symptoms: Anaphylactic reaction, Dizziness, Dyspnoea, Erythema, Flushing, Nausea, Palpitations, Respiratory distress, Swollen tongue, Wheezing, SARS-CoV-2 test negative

Life Threatening? No
Birth Defect? No
Died? No
Permanent Disability? No
Recovered? Yes
Office Visit (V2.0)? No
ER or Office Visit (V1.0)? No
ER or ED Visit (V2.0)? Yes
Hospitalized? Yes, days: 1     Extended hospital stay? No
Previous Vaccinations:
Other Medications: Biotin 1 mg PO daily, Levothyroxine 112 mcg PO daily, MVI tablet PO daily, Paroxetine 20 mg PO QHS
Current Illness: none reported
Preexisting Conditions: Past Medical History (as noted in H&P) ? Acquired hypothyroidism   ? ? Anxiety   ? ? Chronic deep vein thrombosis (DVT) of distal vein of lower extremity   ? ? Chronic midline low back pain   ? ? Complex regional pain syndrome I   ? ? Essential hypertension   ? ? Fibromyalgia   ? ? Gastroesophageal reflux disease without esophagitis   ? ? History of pseudoseizure   ? ? Laryngospasm   ? ? MDD (major depressive disorder)   ? ? RSD (reflex sympathetic dystrophy)
Allergies: cefuroxime (shortness of breath), gadolinium (anaphylaxis, March 2018), iodine (anaphylaxis), quinolones (shortness of breath, "paralyze"), gabapentin (hallucinations), vancomycin (itching) (itching)
Diagnostic Lab Data: COVID-19 antigen negative, BP 126/52, pulse 96 on admission to ED
CDC 'Split Type':

Write-up: Patient is hospital employee who completed screening form for COVID-19 vaccine by answering "no" to all contraindication questions. Approx 10 minutes after receiving COVID-19 vaccine dose # 1, patient was still in vaccine clinic area and complained of dizziness, palpitations and flushing. I observed patient fanning herself with papers. She was escorted out of the immediate clinic room, and assessed by paramedics present as having an anaphylactic reaction. Epinephrine 0.3 mg IM and diphenhydramine 50 mg IV given in clinic, Rapid Response was called overhead and patient immediately transported down the hall to the Emergency Dept. In ED, pt was noted as having swollen tongue, large areas of erythema on face, arms and chest, shortness of breath, nausea, dizziness (per ED physician notes). Pt reported being hospitalized in ICU with COVID disease more than 3 months ago, including intubation (not treated at this hospital), and has been back at work since August 2020. ED physical exam noted bilateral wheezing and patient in acute distress. In ED, pt administered racemic epinephrine 2.25% 0.5 mL via neb, epinephrine 0.3 mg IM, diphenhydramine 50 mg IV, Solu-Medrol 125 mg IV, famotidine 20 mg IV and epinephrine 5 mg/250 mL IV drip (started at 0.118 mcg/kg/min). Acute symptoms reported to resolve in ED. COVID test was negative. ED physician discovered that pt had history of multiple medications, including previous anaphylactic reaction to radiocontrast dye requiring intubation (which was not disclosed on the vaccine screening form). Pt admitted to Telemetry floor for observation. Overnight course was unremarkable, and patient was discharged the following day with prescription for Prednisone taper and prescription for Epi-pen. Advised not to return for second dose of COVID vaccine. EMR updated to reflect possible anaphylactic reaction to Moderna COVID-19 vaccine.

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